A clinical pathway for heart failure reduces admissions from the ED without increasing congestion in the ED

Am J Emerg Med. 2018 Jul;36(7):1202-1208. doi: 10.1016/j.ajem.2017.12.012. Epub 2017 Dec 7.


Background: A multidisciplinary team at a major academic medical center established an Acutely Decompensated Heart Failure Clinical Pathway (ADHFCP) program to reduce inpatient readmission rates among patients with heart failure which, among several interventions, included an immediate consultation from a cardiologist familiar with an ADHFCP patient when the patient presented at the Emergency Department (ED). This study analyzed how that program impacted utilization of services in the ED and its subsequent effect on rates of admission from the ED and on disposition times.

Methods: ADHFCP inpatient visits were retrospectively risk stratified and matched with non-program inpatient visits to create a control group. A Cox survival model analyzed the ADHFCP's impact on patients' likelihood to visit the ED. Multivariable ANOVA evaluated the impact of the program on the patients' likelihood of being admitted when presenting at the ED. The ADHFCP's impact on bed-to-disposition time in the ED was evaluated by Wilcoxon's rank-sum test, as were doses of diuretics administered in the ED.

Results: The survival analysis showed no impact of the ADHFCP on patients' likelihood of visiting the ED, but ADHFCP patients presenting to the ED were 13.1 (95% CI: 3.6-22.6) percentage points less likely to be admitted. There was no difference in bed-to-disposition times, but ADHFCP patients received diuretics more frequently and at higher doses.

Conclusions: Improved communication between cardiologists and ED physicians through the establishment of an explicit pathway to coordinate the care of heart failure patients may decrease that population's likelihood of admission without increasing ED disposition times.

Keywords: Acutely Decompensated Heart Failure; Clinical Pathways; Emergency medicine; Heart failure; Readmissions.

MeSH terms

  • Aged
  • Case-Control Studies
  • Communication
  • Critical Pathways*
  • Disease-Free Survival
  • Emergency Service, Hospital / statistics & numerical data
  • Facilities and Services Utilization
  • Female
  • Health Status
  • Heart Failure / mortality
  • Heart Failure / therapy*
  • Hospitalization / statistics & numerical data
  • Humans
  • Interprofessional Relations
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Retrospective Studies